This is a really important concept developed by Charlie Reynard and Rick Body here in Manchester. There is an accompanying paper in the EMJ that you can read via this link https://emj.bmj.com/content/34/12/A870

This concept could radically change how we make probabilistic prescribing decisions in the ED. Have a listen and look out for a blog post on St Emlyn's soon.

This podcast and presentation was recorded at the St Emlyn's LIVE conference in Manchester 2018. In this presentation Clare takes us through the rationale, principles, training and practice that we need in order to continually develop as prehospital and resuscitation practitioners.

This is a great presentation for anyone interested in continually developing their own and their colleagues practice, delivered by someone who really knows what they are talking about and who works for one of the best developed resuscitation services in the world.

Clare is an Emergency Physician and specialist in Pre-Hospital Care and Retrieval medicine based in Sydney, with Royal Prince Alfred Hospital and Sydney HEMS. She has completed a fellowship in simulation based education, and enjoys training with “real” people - patients, bystanders and the other clinicians we come across as we treat our patients every day. She is a lecturer with the University of Sydney, and is involved in education for the NSW Institute for Trauma Injury Management. When Clare is not working on helicopters or training teams, she is studying yoga or hanging out with her puppy, Archie.

This podcast was recorded at the Intensive Care Society State of the Art meeting in London 2018. Simon Carley interviews Prof Peter Brindley on the interface of technology, humans and humanity in critical care. The audio was recorded live and at the venue so there is a fair bit of background noise, but we hope that this does not distract from a wide ranging and fascinating podcast.

This month we have a podcast on how we approach patients with mental health needs in the ED. It outlines the rationale and delivery of a change in how we manage some of the most vulnerable patients in the ED. We hope you find it interesting and I suspect you will also find it quite challenging. We are aiming to improve the care of patients with Mental Health needs, but in doing so we must face our own prejudices and practices, which are not always healthy.

Editorial note on language – as you listen to the podcast you might be surprised to hear us use words like ‘insane’ in relation to decisions and systems. In some ways it seems incongruous to use such terms in a podcast that promotes a better understanding of mental health issues. We considered taking them out, but after consideration we left them in an attempt to illustrate the false dichotomy between medical and psychiatric needs that is embedded in much of our work. Perhaps the use of language reflects this and makes the point that we can do better.

Why do we need to rethink our approach to Psychiatric emergencies in the ED?

There are a group of life threatening conditions that present to your ED that you don’t deal with, or at least you don’t deal with very well. This group of conditions has a significant mortality and an incredibly high morbidity, but if you are a typical emergency physician you probably don’t think you own the problem. This group of conditions is at least as common as chest pain and yet it’s unlikely that you feel the same level of ownership of the problem.

The issue is of course that of psychiatric illness. In Virchester it accounts for about 1 in 20 patients through the door, and that number is much, much higher if we were to include substance abuse and its related outcomes.

In general, the approach in many UK units is to divide the patient up on arrival into physical and mental health needs. We feel responsible for the physical problem and then we try and offload any psychiatric problems onto the psychiatrists and mental health teams. At the centre of this is the patient who really does not see or feel this dichotomy and we really need to challenge our approach to this.

Such dichotomies are embedded in our systems. I’m sure that many readers will be familiar with the request to ‘medically clear’ a patient in order that they can then be assessed by the mental health team. Bizareer customs and practice take place around these assessments, for example in Virchester the rule that a patient with a heart rate of more than 100 cannot be medically fit for assessment is sometimes used to decline psychiatric assessment. Such informal rules (none are actually written down or appear in any agreed protocol) result in delayed assessments, patient distress and long waits in the ED. I could go on, and whilst there is good and practice amongst all teams and specialities (we are just as bad at the mental health teams in promoting this dichotomy), the point is that we really don’t act in the patient’s best interests by dividing mental and physical health.

This clear difficulty was one of the starting points for the APEX course, which aims to bring psychiatry and emergency medicine together for the benefit of patients, services and staff.

The interview on the podcast is recorded with Prof. Kevin Mackway-Jones who many of you will know through his work with the Advanced Life Support Group. He was the instigator of APLS at a time when there was a clear need for emergency physicians to improve their approach and knowledge of paediatric emergencies. APEx feels the same. A common condition in our EDs for which we are not currently doing the best that we can for our patients and where a joint teaching and learning approach is needed between the ‘tribes’ of medicine.

This could be a game changer to how we manage a very common and very vulnerable group of patients in the ED.

So what’s on the course?

I can’t give you the whole courses here but there are a few principles that underpin the content and approach.

Key points.

It’s co-written and developed between psychiatry and emergency medicine

It’s a symptom based approach (just like APLS) and so it deals with how we deal with the presenting complaint first and not the underlying diagnosis (as you may not know what this is when you are dealing with the patient).

The approach will be familiar to many Eps.

Primary Survey

Resuscitation

Secondary Survey

Definitive management

There is a unified approach. The patient needs an ABC approach for physical health, but in addition and concurrently they also need the AEIOU approach.

A – Assessment of Aggression and Agitation

E – The Environment in which you are assessing the patient

I – The Intent of the patient

O – The Objects the patient has to carry out the intent

U – The Unified assessment (as you will also be carrying out an ABC assessment alongside AEIOU)

Rapid tranquilisation is a key conern for EPs and so there is lots on this that does not automatically default to restraint, a needle and syringe and a significant risk.

Oral tranquilisation works

Ketamine is not the answer to every patient

It’s a risk based approach as every intervention (including no intervention) has a risk

At St Emlyn’s we are letting you know about the course for several reasons. Many of us teach and support the work of the ALSG charity (for free and because we believe in it), but also that we all believe that the care of patients with mental health needs can be improved. They are a vulnerable group who generally get a bad deal when they present in crisis to emergency departments. We know we can do better and we believe that this course will help us achieve our goal to do the best that we can for our patients.

Gosh, when you write it down and think about all the work the rest of the team puts in to teach and learn it makes me kind of proud. Don't forget to join us later this year for the live version at #stemlyneLIVE in Manchester.

This month we cover IV fluids and the never-ending debate around balanced crystalloids vs. saline, we look at working in Africa on secondment or as a placement and we round off with a discussion of the utility of pupillary signs in the prognosis of patients post cardiac arrest.

The Physician Response Unit (PRU) is an innovative service in East London that takes the emergency department to the patient. The PRU is led by Tony Joy, consultant in emergency medicine and prehospital care and is a fairly unique service to the UK.

In this podcast our very own Richard Carden interviews Tony for an in depth understanding of how the service is supporting the entire emergency care system in London.

Simon CarleyJanuary 1, 20180 Comments As 2017 ends and we look forward to 2018 it’s time to reflect on a year with the St.Emlyn’s team. Despite our chronological and geographical dispersal it’s really felt like a team effort in 2017. We have travelled, learned, listened,…Read more

Simon CarleyJanuary 4, 20183 Comments Social media can sometimes give the impression that all is rosy in the world of resuscitation. We hear of the amazing saves, the wonders of ECMO, helicopters and heroic acts with great outcomes, but the reality is of course very…Read more

Chris GrayJanuary 9, 20180 Comments It’s the second time I’ve been to the Northern Emergency Medicine conference, this year held in the sunny city of Durham. I say sunny… I needed my jacket. Last year’s programme was great and included some fantastic speakers, including our…Read more

Janos BaombeJanuary 12, 20184 Comments Last month, I came across a clinical review published in the Annals of Emergency Medicine1 that got me really excited! It got me excited (in a geeky professional sense of course…) as it covered a topic that causes significant…Read more

Natalie MayJanuary 16, 20183 Comments On Reflection I’ve been reflecting on reflection for some time now, at least since I started formally collecting my lessons from Sydney HEMS and probably even before that, because this sort of meta nonsense is something medical education enthusiasts like…Read more

Richard CardenJanuary 21, 20182 Comments You might be aware that an exciting new trial has started called Cryostat-2. This is exciting as it has the potential to improve patient outcomes, but also because it will involve all the Major Trauma Centres in England and 8…Read more

Dan HornerJanuary 22, 20184 Comments So another year, another Critical Care Reviews meeting. Rob is doing an absolutely fantastic job with these, inviting lead authors from major critical care trials to present and defend their work. In fact, this is going so well that this…Read more

Simon CarleyJanuary 28, 20180 Comments Last weekend, the BeSEDiM (Belgian Society of Emergency and Disaster Medicine) organised their annual symposium. It is the scientific organization of the Belgian emergency physicians with Said Idrissi as chairman. 13 years ago, Belgian Emergency medicine was born as a…Read more

Simon CarleyJanuary 29, 20180 Comments This is a guest post from our good friend Stevan Bruijns aka @codingbrown Stevan has been an advocate of international emergency medicine for many years and he, like us feels that there is much that high income countries can do…Read more

In this episode, the fabulous Liz Crowe (@LizCrowe2) discusses how to approach debriefing after critical (and non critical) incidents in healthcare. We focus on the debriefing that takes place 5-7 days after an incident. For more on a "hot" debrief listen to this podcast by Ashley Liebig and Rob Orman (http://blog.ercast.org/beating-stress-and-the-hot-offload-with-ashley-leibig/)

Rick and Simon talk about critical appraisal and diagnostic studies. How does a PICTR question work and how can you use it to assess the quality of a published study, and how can it be used in research design.

Rob MacSweeney from the incredible Critical Care Reviews website joins Simon to talk about the forthcoming CCR meeting in Belfast and the news that the eagerly awaited ADRENAL trial will be releasing it's results this Friday.

Below is the 'blurb' from the CCR website. The bottom line is that this is a unique and incredibly valuable event and there is still time to get there.

S

Every year the Critical Care Reviews Meeting brings the chief investigators for the biggest and best critical care trials of the year to Belfast to discuss their work. The programme is put together throughout the year as these trials either near completion or are published, but we have three confirmed mega trials to open registration with:

The Meeting is getting increasingly popular and in 2017 sold out for the first time. If you haven't yet been, and are wondering what it's all about check out the promotional movie. In addition to the big trials, we also review the remaining major trials of the year, have talks on "how I manage..." specific conditions by these experts, and take a look at the dark arts of critical care research with some of the best trialists in the world. In addition, every delegate will receive a free copy of the "Critical Care Reviews Book 2018" summarising, critiquing and placing in context the best critical care trials of the year. If you are unluckily enough not to be able to make it, all talks will be recorded and made freely available online after the event. You can check out the previous talks here and last years book here

The Critical Care Reviews Meeting is a small, intimate event where you get the opportunity to meet the faculty, ask questions and have a beer with them. The famous "Informal Chat", held at the end of the day, guarantees this opportunity to ask some real questions and get some very interesting answers. Stay for dinner afterwards, overlooking the slipways where RMS Titanic and Olympic were built and launched. Year on year delegate feedback has been incredibly positive confirming this as one of the best meetings around. In 2017 delegates travelled from across Ireland, the UK, Europe, India, the USA and Australia. Don't wait too long before registering as numbers are limited and the meeting will sell out.

Natalie and Simon discuss reflections, e-books and life at Sydney HEMS. This week we have added Lorikeets in the background (Nat recorded at Coogee Bay in NSW). We think they sound cute so we've kept them in (or rather we could not edit them out).

A quick summary on how you can use group messaging systems in a major incident. A vast improvement on telephone cascades BUT you have to set this up in advance. If you make it up on the day it will be a disaster. Here's the tips and tricks from the Virchester team. You can read more here http://stemlynsblog.org/tag/whatsapp/

Simon (@EMManchester) and Iain (@docib) review some of the articles from the St Emlyns blog site (http://stemlynsblog.org/) from recent weeks and chat about the current state of Emergency Medicine in the UK.

I recently met up with some amazing UK docs working in South Africa at the EMSSA conference. This conference was held in Sun City near Johannesburg and brought together emergency physicians from across the contient.

It was great to catch up some UK docs who were on postgraduate electives working in hospitals like Khayelitsha which you may remember from this amazing blog by Robert Lloyd.

So please listen, learn and get in touch if it's something that you want to do.

Iain (@docib) and Liz (@LizCrowe2) discuss one of the hottest topics in medicine - Burnout. What is it, who gets it and what can we do about it? Liz brings her huge knowledge and experience to a topic that is often discussed, but not always understood. Essential listening.

Iain and Simon chat through our top ten trauma papers for 2016. Lots here for anyone who is interested in trauma including whole body CT, traumatic cardiac arrest, neurosurgery in severe head injury and much more. As ever we'd suggest you read the original papers, references for which along with a blogpost can all be found here http://stemlynsblog.org/top-10-trauma-papers-2016-st-emlyns/

In a new podcast format Simon (@EMManchester) and Iain (@docib) discuss the month's offerings from the St Emlyn's blog and podcast (www.stemlynsblog.org).

It's been a month full of interesting posts on subjects as diverse as Thrombolysis in Stroke (Alan Grayson), The Future of Emergency Medicine in the Social Age (Simon), Cardiac Arrest Centres (Simon), Love in Critical Care (Liz Crowe), Transfers (Nat and Simon), Thrombolysis in PE (a guest post from FOAMed legend Anand Swarminathan) and Benzos in Back Pain (Janos). Head to the website for the articles themselves and all the references and links you need.

We're aiminig to make this a regular monthly podcast - let us know if it's useful and enjoyable and how we could make it even more educational.